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Multifinality: Same underlying cause, different disorders.
Jeremiah Weinstock, PhD OPG Summit 2014
Berkeley, CA
Workshop Outline
1. Defining multifinality and its application to psychiatric disorders.
2. Common risk factors for gambling disorder and other psychiatric disorders.
3. Treatment implications of multifinality
A Related Concept: Equifinality Several pathways to the same outcome.
Behaviorally Conditioned
Emotionally Vulnerable
Antisocial & Impulsivity
Gambling Disorder
Pathways ModelBlaszczynski & Nower
(2002)
Classical and Operant
Conditioning
What is MultifinalitySame underlying factor can lead to several different psychological outcomes.
DisorderA
Disorder B
DisorderC
Underlying Factor
What is MultifinalitySame underlying factor can lead to several different psychological outcomes.
EXAMPLE:
However, context and expression of the underlying factor varies across disorders.
Social Anxiety Disorder
Anorexia Nervosa
Major Depression
Perfectionism
MultifinalityExplains why not everyone who is exposed to trauma develops post-traumatic stress disorder (PTSD).
Requires examination of a client’s entire developmental history, instead of current symptom profiles.
DSM-5 is based upon observable symptoms that typically present together. It is not based upon etiology.
MultifinalityLeads to several conclusions about psychopathology:
• Genes and/or events are not always deterministic.
• The same underlying processes contribute to the development of many disorders.
• Helps explain comorbidity and why disorders reliably cluster together.
• The DSM classification scheme has limitations.
Gambling DisorderNot everyone who gambles develops the disorder:
– About 85% of Americans have gambled in their lifetime.
– About 2-3% of Americans experience sub-clinical problems related to gambling
– About 1% of Americans meet diagnostic criteria for gambling disorder.
Multifinality: Underlying ProcessesHow can we think about these processes?
Distal Risk Factors
Nolen-Hoeksema & Watkins, 2011
Multifinality: Underlying ProcessesHow can we think about these processes?
Proximal Risk Factors
Distal Risk Factors
Nolen-Hoeksema & Watkins, 2011
Multifinality: Underlying ProcessesHow can we think about these processes?
Proximal Risk Factors
Distal Risk Factors
Addiction Disorders
Antisocial Personality
Disorder
Generalized Anxiety Disorder
Nolen-Hoeksema & Watkins, 2011
Multifinality: Underlying ProcessesHow can sexual abuse lead to antisocial personality disorder?
Poor Attachment
Sexual Abuse as a child
Antisocial Personality
Disorder
Multifinality: Underlying ProcessesHow can sexual abuse lead to addiction?
Copes by dissociation
Sexual Abuse as a child
Addiction Disorders
Multifinality: Underlying ProcessesHow can sexual abuse lead to generalized anxiety disorder?
Hypervigilence for threats
Sexual Abuse as a child
Generalized Anxiety Disorder
Gambling & AbuseChildhood abuse is a significant risk factor for gambling disorder (and many other disorders).
The link between the two is posited via proximal risk factors of:
1. Early maladaptive schemas 2. Use of emotion focused coping
Hodgins et al., 2010; McCormick et al., 2012; Petry & Steinberg, 2005; Shorey et al., 2012
Gambling & AbuseChildhood abuse is a significant risk factor for gambling disorder (and many other disorders).
The link between the two is posited via proximal risk factors of:
3. Gambling at a slot machine is one method to cope with one’s emotions. It is a way to dissociate.
4. Within gamblers, dissociation is linked to $pending more than one intend$.
Hodgins et al., 2010; McCormick et al., 2012; Petry & Steinberg, 2005; Shorey et al., 2012
Gambling Disorder Comorbidity Within gambling disorder, the lifetime prevalence rates of other disorders are:
More often than not, the other disorder develops first.
Kessler et al., 2008; Petry, Stinson & Grant, 2005
Alcohol U
se Diso
rder
Mood Diso
rder
Anxiety
Disord
er0
30
60
90
Prev
alen
ce R
ate
(%)
Gambling Disorder & Alcohol How are the two related?
– Sensation seeking• Desire to experience strong feelings and arousal
– Impulsivity• Rash decision making without considering
consequences
– Interaction between the two• Bad decisions are made when intoxicated.
Gambling Disorder & MoodHow are the two related?
• Gambling in response to depression:– Gambling is an easy way to induce positive affect (i.e.,
negative reinforcement).– “Relieves” social isolation
• Gambling causes depression:– Losing money gambling temporarily induces
depressive affect.– Social isolation frequently occurs due to hiding the
problem from others.
O’Brien, 2011
Gambling Disorder & AnxietyA client stated, “I get very frightened and am socially awkward. Gambling is a way to be social without having to be social.”
The severity of gambling disorder is positively associated with comorbid anxiety disorders.
El-Guebaly et al., 2006
Comorbidity: Treatment Implications
Comorbid disorders complicate gambling treatment:
– History of substance use disorder negatively impacts ability to achieve abstinence from gambling.
– History of a mood disorder increase length of time it takes to begin a period of abstinence.
– Current alcohol use disorder increase risk of relapse.
Hodgins & el-Guebaly, 2010
Limitations of DSM-5The development a psychopathology is massively multi-factorial.
Need to go beyond a diagnosis of common observable symptoms and examine what factors influence and/or maintain the behavior.
Integrated TreatmentsIn a sample of individuals diagnosed with both PTSD & gambling disorder:
– PTSD treatments were perceived as more helpful
A pilot study of Seeking Safety, a treatment for comorbid PTSD & substance use disorders, was tested with gambling disorder.
– Efficacious in reducing both gambling and PTSD symptoms.
Najavits, 2011; Najavits et al., 2013
Integrated Treatments
Korman et al., 2008;
Integrated TreatmentsIn a sample of individuals with gambling disorder and anger issues:
– Compared to TAU, an integrated treatment led to greater treatment engagement, reduction in gambling behavior, substance use, and anger
Korman et al., 2008;
Next Steps for Clinical PracticeDo I need to become a jack of all trades?
– No, but improved assessment and screening is beneficial for all clients.
At my clinic, the primarily modality of treatment is group therapy. How do I tailor group treatment to diverse clients?
– Groups focused on treating underlying processes?• Dissociation, emotional regulation (e.g., anger),
impulsivity
SummaryMultifinality suggests that common underlying factors can lead to diverse outcomes.
• Helps explain comorbidity
Response to early events, and more immediate life events influence the path/outcome.
Ignoring these underlying factors during treatment may be detrimental to our clients and their long-term well-being.
